Severe ingrown toenail with hypertrophic skin bridging: A case report and review of the literature

Abstract

We present a case report of an 18-year-old male who was diagnosed with a chronic non-congenital ingrown toenail to his right hallux with skin bridging spanning the mid-portion of the nail plate. The patient elected to pursue surgical correction and underwent a Winograd procedure under monitored anesthesia care. The incision sites healed without incident.

Introduction

An ingrown toenail can be defined where the nail plate has penetrated the surrounding soft tissue causing hypertrophy of the soft tissue with associated pain. The etiology of the ingrown toenail is one that is multifaceted. It can be traumatic, biomechanical, congenital, and occasionally systemic. ¹ No matter the etiology, the end result is an increase in force from the keratinized nail plate exerting pressure at the nail folds leading to pain and hypertrophy of the surrounding soft tissue. The nail consists of a nail plate, nail bed, nail fold, and the germinal matrix along with the surrounding neurovascular structures. The nail bed consists of thin layers of epidermal and dermal tissues. The proximal aspect of the nail bed is continuous with the germinal matrix. The germinal matrix is essential to mitotic activity and in migration of the nail plate cells. It is thin at its proximal end and sits directly on the periosteum of the distal phalanx. The eponychium covers the matrix proximally and extends distally to transition as the nail bed. ¹

Heifetz and Frost classified ingrown toenails in three stages. ² Typically conservative treatment is the treatment modality of choice for mild or stage 1, with surgical intervention reserved for stage 2 and above. ³ The case described in this report does not fit the classification system as it is a rare and atypical occurrence with the need for surgical intervention due to skin bridging across the dorsal nail plate with absence of infection.

We believe that cases of ingrown toenail secondary to hypertrophy of the surrounding soft tissue without underlying infection or traumatic onset are unusual and to the authors’ knowledge only two other such cases have been described in literature.^3,4 We present a case where the medial and lateral nail folds have significant hyperplasia to the effect of spanning the mid-portion of the hallux nail plate. Seyfettinoglu et al. have previously described the Winograd procedure in a case study for use in similar hypertrophied cases. ⁵ This case report describes the surgical excision of the nail and germinal matrix using a modified Winograd procedure similar to the two previously described case reports.

Case report

The patient is an 18-year-old male with past medical history significant for anxiety and asthma who presented with a longstanding ingrown toenail deformity to his right hallux. He and his family were uncertain as to the exact duration of the affliction, but state this was not a congenital deformity and likely developed over the course of a few years. The patient denies seeking treatment or having the toenail evaluated prior to this presentation. The patient delayed presentation and kept his ingrown toenail hidden from his parents secondary to anxiety associated with seeking treatment. Both patient and family denied any recent or longstanding signs of infection to the affected digit.

On physical exam the right hallux toenail was of appropriate thickness and consistency. The nail plate was clear and free of any clinical signs of onychomycosis. The medial and lateral nail folds appeared hypertrophic with the unusual addition of an area of bridging hypertrophic skin spanning the mid-portion of the nail plate dorsally (Figures 1 and 2). There was mild pain with palpation but no appreciable signs of clinical infection. No purulence, drainage, malodor, erythema, edema, or focal increase in skin temperature was present. No skeletal abnormalities were found on radiographic exam of the forefoot. The remaining toenails were free of deformity and within normal limits for length, thickness, and coloration.

Figure 1.

Anteroposterior (AP) pre-operative imaging.

Figure 2.

Lateral pre-operative imaging.

The patient was positioned on the operating room table in a secure supine position. Monitored anesthesia care was administered per the anesthesiologist and a pre-operative local infiltrative block consisting of 7 cc of a 1:1 mix of 1% lidocaine plain and 0.25% marcaine plain was administered in an H-block fashion. The extremity was prepped and draped in standard aseptic technique using betadine and hemostasis was maintained with the use of an ankle tourniquet.

Initially the skin bridge overlying the mid-substance of the digit was sharply excised in total and passed to the back table where it was collected in formalin and sent to pathology for histopathological evaluation. The excised tissue measured 2 cm in length and ranged from 0.4 to 0.7 cm in diameter. Both the medial and lateral most 15% of the hallux nail plate were resected using an English anvil and avulsed free from the nail matrix. A Winograd technique was then used to sharply excise both the medial and lateral hypertrophic nail borders including the proximal germinal matrix. The remaining nail border tissue was then advanced to the nail plate using nylon suture bilaterally. Throughout dissection no purulence, drainage, or frankly infected or non-viable tissue was encountered. The underlying soft tissue was wholly granular. The tourniquet was let down and a prompt hyperemic response was appreciated to the digit with immediate capillary fill time distally (Figure 3).

Figure 3.

AP immediate post-operative imaging.

The patient was discharged to home per post-anesthesia care unit protocol with prescriptions for a short course of prophylactic post-operative antibiotics and narcotic pain medication.

The patient followed in office for serial post-operative evaluation. The sutures were removed in office on post-op day 14 and the soft tissue had healed without incident. The soft tissue to the medial and lateral aspects of the nail border remodeled to appropriate contour with no signs of potential recurrence of the dorsal bridging skin.

The pathology report was negative for any concerning neoplastic process and showed mild to moderate acute and chronic inflammation, dermal fibrosis, and hemosiderin laden macrophages on examination of the collected tissue.

The patient followed again at 3 (Figure 4) and 10 months post-operatively and showed maintenance of the remodeled soft tissue to the hallux with no signs of further ingrowth, wound development, or other complication.

Figure 4.

Post-operative imaging.

Discussion

According to the Frost classification scheme, stage 3 nails have a normal nail bed accompanied by soft tissue hypertrophy in the lateral border and generally require surgical correction. The classification scheme proposed by Frost, however, does not include a grade encompassing the severity of our presented case. Hypertrophy of the skin folds is not an uncommon finding with ingrown toenails and is generally limited to the medial and lateral nail borders. This case is rare in that the hypertrophic tissue spanned the mid-portion of the nail plate effectively creating a skin bridge. To the author’s knowledge, an ingrown nail of this severity has only been presented in the literature two times prior to this case report.

It is hypothesized that if the ingrown nail affects both nail borders and remains untreated, hypertrophic granulation tissue can transition into epithelialized fibrous tissue and result in bridging of the nail plate. ² It has been suggested that this level of severity be considered an additional fourth stage to the Frost classification scheme.

Although exceedingly rare, severe ingrown toenails with a hypertrophic skin bridging tissue component can be successfully treated with complete excision and bilateral Winograd soft tissue rearrangement. Although unlikely to be secondary to a neoplastic process, the authors still recommend histopathological evaluation of the excised tissue.